http://leader.pubs.asha.org/article.aspx?articleid=2292339Asperger Syndrome Across the Home and School DayAsperger syndrome (AS) is considered high-functioning on the autism spectrum. Being a relatively new diagnosis—first recognized in the Diagnostic and Statistical Manual (4th ed.) in 1994, although actually discovered in the 1940s—assessment and treatment approaches for the syndrome are still being defined. AS is considered a “mild” form of autism, ...2003-09-01T00:00:00FeaturesMichelle Garcia Winner

Michelle Garcia Winner, is an SLP who specializes in the treatment of students with social cognitive deficits, which includes diagnoses such as Asperger syndrome, autism, and nonverbal learning disorder. She runs a private practice in San Jose, CA, where she works directly with clients, consults with families and schools, and travels nationally giving workshops. Contact her by e-mail at michelle@socialthinking.com.

Michelle Garcia Winner, is an SLP who specializes in the treatment of students with social cognitive deficits, which includes diagnoses such as Asperger syndrome, autism, and nonverbal learning disorder. She runs a private practice in San Jose, CA, where she works directly with clients, consults with families and schools, and travels nationally giving workshops. Contact her by e-mail at michelle@socialthinking.com.×

Asperger syndrome (AS) is considered high-functioning on the autism spectrum. Being a relatively new diagnosis—first recognized in the Diagnostic and Statistical Manual (4th ed.) in 1994, although actually discovered in the 1940s—assessment and treatment approaches for the syndrome are still being defined. AS is considered a “mild” form of autism, but that designation is relative—it’s mild only when compared to persons with more severe forms of autism. AS is a lifelong condition that affects social, school, and work abilities for the great majority who live with the disorder.

AS is primarily a deficit of social cognition and social communication—“social,” that is, meaning any interpersonal interaction and not just those related to fun. However, one of the more obvious symptoms of those with AS is their weakness in the development of social pragmatic skills, which makes for strained peer relations. Because of this, many clinicians and parents perceive that the primary treatment approach for the speech-language pathologist is to teach those with AS social skills within a group using same-aged, typically developing peers as models.

Although this approach has some merit, fundamentally it is weak if it constitutes the primary treatment. Persons with AS need a much fuller treatment approach, one that explores deeper social thinking lessons and related communication nuances across a range of common but related activities, namely interpreting and producing creative expression through reading, written expression, communication interaction, and personal problem solving.

A key strength of persons with AS is that they generally function with normal to above-normal intelligence on traditional measures of intelligence. This implies that they have the ability to learn abstract concepts, as long as the concepts are introduced in concrete ways. To gain social understanding of the world, persons with AS have to learn cognitively how to think socially and produce related skills that they did not learn intuitively. At our clinic we describe this as teaching “social thinking and related skills.” This approach provides lessons in why we would employ a variety of social skills prior to teaching and expecting the production of related skills. It is based on the belief that the inadequate development of social pragmatic skills emerges from poor to weak underlying ability to think socially, which, in turn, is referred to as having “weak social cognitive skills.”

This approach was developed through observing the impact of direct clinical intervention on students with AS across the school years and into adulthood. One of the critical concerns of teaching a purely social skills approach is its lack of carryover into less-structured environments. An example of the difference between teaching purely “social skills” and teaching “social thinking and related skills” can be explored through how we teach the concept of eye contact. The traditional, more purely behavioral social skills approach is to say to students, “look at me,” when they fail to use this skill; various rewards such as praise or tokens are then provided to reinforce the performance of this skill.

Social Thinking Approach

The social thinking approach views eye contact as a tool that helps to facilitate recognition of what someone else may be thinking as well as how they may be feeling about the communication interaction. We talk to students about “thinking with their eyes” rather than use the term “eye contact.” We encourage them to be detectives who have to learn to observe people and the context within which they are communicating to help them make better guesses about the nature of the exchange. This is a much broader approach than simply asking someone to “look at me,” and it provides a depth of information that helps students generalize the related skills with more consistency, according to reports from educators and parents.

Failure to understand the purpose of the eyes not only affects one-on-one social interactions, but can also strongly affect participation within structured group learning environments. When teachers request a student’s participation, they often do so using directed eye gaze rather than calling a student’s name. When they want to ask a question, they look right at the student and then follow with the question. Most students understand intuitively to whom the teacher is directing her attention, but those who lack the ability to easily attend to the information provided through other people’s eyes may just call out the answer.

To help teachers educate this student about appropriate nonverbal communication, I encourage teachers to keep their eyes focused on the student they are talking to, hold up the palm of their hand in the direction of the student, and say, “I was looking at (the student’s name). I was talking to this student. I am not talking to you right now.” By doing this, the teacher provides cognitive information about the process of communication that helps the student learn how to avoid blurting out a response. It is much more helpful than telling the student, “Don’t yell.”

In fact, social cognitive information and related social pragmatic skills are deeply embedded in the requirements for learning across the school and home day. Social cognition is the mortar binding together the more factual knowledge accumulated across the day. It is required to assist with tasks such as reading comprehension of socially abstract concepts (literature), written expression, interpreting non-literal directions, participation as part of a group in the classroom, participation with peers or family members during unstructured time, organizational skills both within the classroom and during homework assignments, and working together with peers on class projects.

The ILAUGH Framework

I developed the ILAUGH framework of social cognition to explore the variety of areas that contribute to social thinking and related skills. This framework pulls together knowledge accumulated through research and verified through clinical experience to demonstrate how deficits in social functioning affect students across their entire day, socially and academically.

The framework also demonstrates how we can take larger and vastly complex concepts, such as problem solving and effective communication (including conversations), and break down our area of focus and educational lessons into much more defined and concrete elements to help students learn building blocks of social cognition and related skills over time. It is important to recognize that helping students with social cognitive deficits takes time, and that their needs change as the curriculum and social demands placed upon them become more complex across time.

The elements of the ILAUGH framework include:

I = Initiation of Language. This is the ability to use language skills to seek assistance or information. Students’ ability to talk about their own interests can be in sharp contrast to how they communicate when they need assistance or in developing relationships. A core element of communication competence is being able to ask for help or clarification. It is also critical for students to understand how to initiate a typical communication interaction so that the person they are talking to wants to continue to talk to them. SLPs need to work with students on using communication skills to become self-advocates. This is critical for success beyond the public school years.

L = Listening With Eyes and Brain. Most persons on the autism spectrum have difficulty with auditory comprehension. Listening requires more than processing auditory information. It requires integrating information gleaned from the environment along with nonverbal communication cues to understand the deeper concept of the message, or the ability to make a smart guess about what is being said when the information is not clearly heard or understood. “Active listening” or “whole-body listening” are other terms used to help students learn that listening involves far more than hearing.

A = Abstract and Inferential Language/Communication. Communication comprehension depends on one’s ability to recognize that most language/communication is not intended for literal interpretation. To interpret adequately, one must have the flexibility to make smart guesses about intended meaning. Abstract and inferential meaning is often carried subtly through verbal and nonverbal communication. It also requires students to consider the point of view and/or past experiences of the speaker that contribute to underlying meaning. Weaknesses in abstract/inferential language may require SLPs to help students work toward increasing flexibility of literal and figurative forms of language, as well as to explore the multitude of nonverbal components associated with communication. Although we may investigate the use of idioms to help introduce the difference between literal and figurative language, there are many other lessons students need related to this concept. Helping them increase their ability to interpret socially laden comics is one example of this. Students demonstrate weaknesses in interpretation of language (verbal and nonverbal) in every aspect of their school day, including reading comprehension, written expression, and conceptual math problems.

U = Understanding Perspective. This is the ability to understand one’s own and others’ emotions, thoughts, beliefs, prior experiences, motives, and intentions. We generally intuitively acquire this skill early in life and continue to develop perspective. Most students have acquired a solid foundation in this ability between the ages of 4 and 6. Understanding perspective is key to participating in any type of group (social or academic), as well as to interpreting information that requires understanding of other people’s minds, such as reading comprehension, history, social studies, or social interaction. Perspective-taking is critical for spontaneous social communication success. It is the first step of conversational language. For SLPs to truly be communication specialists, we need to learn how to teach students about the act of thinking about others prior to using language.

G = Gestalt Processing/Getting the Big Picture. Information is conveyed through concepts, not just facts. When conversing, participants should intuitively determine the underlying concept being discussed. When reading, one has to follow overall meaning (concept) rather than just collect a series of facts; concept formation is the integration of factual and inferential information. Conceptual processing is also key to the development of organizational skills. One has to consider the overall task before it can be broken down into smaller components that need to be worked on independently while always keeping sight of the eventual product. Prioritizing comes after organizing and requires another set of conceptual information. Given the abstract challenges of persons with AS, most crave structure but find it extremely difficult to create it. It is hard for them to create organizational strategy and then follow through with related tasks outside of topics of interest. Conceptual processing is interwoven into executive functioning and is an integral part of developing functional life skills in the adult years. SLPs can work with students on learning to grasp overall meaning before focusing on individual skills to be performed during the communication or learning process. Visual graphic organizers, outlines, and the use of comic strip conversations can help tremendously.

H = Humor and Human Relatedness. Most of the clients I work with actually have a very good sense of humor, but frequently feel anxious because they miss many of the subtle cues that help them understand how to participate successfully in their school work or with others. It is important for educators/parents to work compassionately and with humor to help minimize children’s anxiety. As students get older, they also may use humor inappropriately. In their quest for social interaction, they may use humor they have observed elsewhere, but without the appropriate knowledge as to where or when to use it. At times, clinicians have to explore with students how best to apply humor, what type of humor is appropriate in different contexts, and when to avoid its use altogether.

Written Language

By fourth grade, students are expected to write down their ideas without having to think about the physical task of writing. From my experience, roughly 70%–80% have challenges associated with written language because of fine motor and muscle tone difficulties. While occupational therapy can help improve handwriting skills, the fact that written expression requires many ILAUGH framework concepts (e.g., perspective-taking, abstracting information, cognitive organization, and language formulation) means that this task becomes overwhelmingly complex when students are requested to write out complete thoughts in paragraph or essay form.

It is important to realize that for handwriting skills to be functional, they should not only be neat but also must be produced in a timely, efficient manner that students can sustain across time, requiring little cognitive energy. Recognizing alternatives to actual writing of words such as the use of keyboarding or dictation software should be explored early in the educational process to alleviate further educational stressors.

Moving Forward

Clearly, our students find the school day much more difficult to cope with as they move through their years of education, regardless of how high their IQ score is. Whereas the early school years (kindergarten to second grade) are geared toward teaching the facts of learning (e.g., basic math, writing, and reading skills) and very basic play skills, the later years of education (fourth grade and beyond) are devoted to interpretation and critical thinking. During these later years, the level of social interaction expected with peers also becomes increasingly complex. For this reason, students with AS are much more likely to grow into the need for a specialized education treatment plan, rather than out of the need for extra services as they age.

The great frustration for parents and educators alike is that it is very difficult to prove our students have significant deficits based on current standardized tests of intellectual, educational, or speech and language skills. Given that most standardized tests create a highly structured environment through format and administration, our students with good-to-excellent concrete thinking abilities find it relatively easy to perform well on tests. However, their ability to achieve success on these same types of skills in more spontaneous (unstructured and abstract) environments can be far more challenging.

Thus, many of our students have an “invisible disability,” since it is difficult to prove their deficits based on test results. Nowhere is this more profound than with the standardized assessments provided by SLPs. Our assessments do a reasonably good job of measuring basic technical language skills, but they are not able to capture how children will use these skills when they must respond and formulate language within a narrow window of time while also considering the perspective and abstract meaning of others and the communication environment.

For example, I may be able to assess a child’s familiarity with the concept and definitions of idioms through standardized tests. However, because these subtests are untimed, allowing the student to take as long as the examiner finds reasonable to define the concept requested, this student may score within the normal limits. But, does achieving a good score on this subtest imply that the student demonstrates communication competence in this skill? Effective communication is highly time-dependent; communication partners are generally expected to respond to each other within a very narrow window of time (1–2 seconds). Would students be able to score within normal limits on a subtest if we held them accountable to the constraints of time? Even standardized tests of pragmatic language skills only assess the more superficial aspects of social cognitive knowledge. We do not currently have any standardized tests for exploring spontaneous communication in natural contexts or tests that place time constraints on processing and responding to complex information. As SLPs, we have to critically think about the validity of our testing in terms of its ability to truly assess overall communication competence.

For students with social pragmatic deficits, the best assessment is a qualitative one. The professional must observe children across multiple contexts (unstructured and structured) and compare their functioning to the level of their peer group. Social pragmatic communication skills are far too complex to reasonably assess in their entirety through standardized measures. Although some measures will add information to the full assessment battery, no assessment of a student with AS can be valid if it is completely based on standardized tools. This is not only true for the speech-language evaluation but for all child-based evaluations (e.g., psychological and educational).

It is important then for the SLP to incorporate functional social pragmatic language samples into their assessment batteries. Although all school districts prefer that students clearly qualify for speech-language pathology services based on low test scores, it will be important for the SLP to be able to professionally represent their student at the individualized education program (IEP) meeting. This means that they help to explain to the IEP team why standardized scores do not assess social cognitive knowledge, yet that social cognitive knowledge is critical for success across the school day and ultimately required for students to become independent adults.

The information shared at the IEP meeting is not only based on social pragmatic observations, but also on interviews with the child’s caregivers (teachers and parents). It will be important for the SLP to work as part of a coordinated diagnostic team, discussing assessment plans with at least the school psychologist and resource teacher. Federal law allows a child to be qualified for services as long as the IEP team agrees on the fact that the child has a significant need for services. SLPs, as IEP team members, constantly have to work at refining their own skills in how best to represent and discuss the current and long-term impact of students with social cognitive deficits and related social pragmatic skill deficits.

Role of SLPs

Students with AS are fascinating to assess and work with because they continue to teach us so much about the complexity of social cognition and its impact on social and life skills, and on academic and career development. They also help us to learn about the communication process and how no communication skill, however simple it may appear, can be taken for granted.

SLPs can perform a pivotal role by helping to teach students with AS and their educational professionals and caregivers about social thinking and related skills across the school day. These lessons last a lifetime.

One Parent’s Perspective

Asperger Syndrome Across the Home and School Day

by Tina Mullins

My son is 20 years old, has graduated from college, and has a great job as a computer programmer. But long before the school or the professionals intervened, we were concerned about his development. He started showing symptoms of Asperger syndrome (AS) when he was 10 months old. His first diagnosis was Pervasive Developmental Disorder at age 3, then AS at age 13.

AS is a family problem. My son did not seek my affection or my attention. He was confused about the words or phrases I used, and because he couldn’t attach meaning to vocal inflection, he didn’t know whether I was angry or scared. He didn’t react to my reprimands and appeared to be defiant. He tended to over- or under-react to events in his life. He was often frustrated that we did not understand what he was trying to say. Everything triggered an explosion. It was like living in a war zone. We all had to adapt in order to have peace at home.

Eye gaze was a big issue. Since facial expression and body language were meaningless, my son viewed these as interfering noise when he was trying to understand someone’s message. The only way he could interpret his environment was through words. His behaviors needed to be described with words. Emotions needed to be ranked and matched to events. Facial features and hand gestures needed to be explained, and intonation and volume needed to be defined.

Literal thinking often got him into trouble, as he did exactly what he was told. Teachers didn’t grasp the limitations of his black and white thinking. “Turn your papers over to begin a test” (when repeated twice) meant to turn your papers over twice so that the words were face down. A four-minute timed test meant he needed to watch the clock 50% of the time, since the timing was just as important as answering the questions.

I volunteered for every possible field trip and classroom activity and spent many hours observing his behavior and that of those around him. If he did not understand a behavior or facial feature, I would explain it. If he reacted inappropriately, I would show him another approach.

Most importantly, I trusted my instincts and advocated on his behalf. When a recommendation was made that did not match my perceptions, I strongly presented my views and supported them with written documentation. At the end of high school, the staff told me that not only had I taught them how to help my son, but I also taught them to see signs of needed intervention for previously unidentified students.

Tina Mullins is ASHA’s director of audiology practice in health care. Contact her by e-mail at tmullins@asha.org.